Select Grade Grade PreK Grade K Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6 Grade 7 Grade 8

Male Female

Camp(s) Child Enrolled

Winter

Select Relation Parent/Step Parent Grandparent Aunt/Uncle Caregiver Friend/Neighbor Other

Select Relation Parent/Step Parent Grandparent Aunt/Uncle Caregiver Friend/Neighbor Other

Yes No

Relation Parent/Step Parent Grandparent Aunt/Uncle Caregiver Friend/Neighbor Other

Pick Up? Yes No

Emergency? Yes No

Relation Parent/Step Parent Grandparent Aunt/Uncle Caregiver Friend/Neighbor Other

Pick Up? Yes No

Emergency? Yes No

Relation Parent/Step Parent Grandparent Aunt/Uncle Caregiver Friend/Neighbor Other

Pick Up? Yes No

Emergency? Yes No

Are Immunizations current? Yes No

Help us provide a safe and respectful environment for your child. List any conditions requiring consideration, accommodations or restrictions while at camp (e.g. asthma, low vision, hearing impaired, high functioning autism, cast on left arm, ADHD ).

By initialing, in the event an emergency arises where it is necessary for the student to be treated by other than the family physician, I hereby give my permission for him/her to be treated by a qualified physician or at a hospital. If necessary to the treatment, transportation by ambulance is also authorized. (Parent or Guardian is responsible for payment of medical treatment.) San Diego Natural History Museum and its staff and volunteers assume no responsibility for illness or injury which might occur during these classes.

By initialing, I understand that should the behavior of my child endanger the safety of others persons or themselves or cause unmanageable disruption to the class, I may be called to supervise my child and/or remove him/her from the class. I will review behavior expectations with my child before camp begin.

By initialing, I hereby grant permission to the San Diego Natural History Museum, on my own behalf and on behalf of my spouse and/or child(ren), to use any photographs, videotapes, or any other likeness obtained in the course of this program, in any promotional, educational or other materials produced by or for the San Diego Natural History Museum, and I hereby waive any and all right to control, inspect, or approve such usage by the San Diego Natural History Museum.